People develop foot and leg ulcers for a variety of reasons: poor circulation, swollen legs, complications from diabetes, burns, and injury. In my practice, while I do treat ulcers that arise from all kinds of circumstances, the majority of the wounds I see are due to diabetes and issues with circulation.
There are two types of ulcers caused by issues with circulation. If someone has poor circulation, or blood flow, in their feet, their skin will often become very thin and fragile. A very small injury is all that is needed to break their skin and cause an ulcer. Sometimes these patients develop ulcers because the blood flow is so poor that the skin simply can’t survive.
If the ends of your toes are pale with red dots on them or have a blue or purple tint, you may have poor circulation in your feet. When the circulation is poor enough, the skin will die from a lack of oxygenated blood. This can cause ulcers and gangrene. Diabetes, smoking, obesity and a weakened immune system all increase the risk of developing gangrene.
Gangrene:There are two types of gangrene: wet and dry. Dry gangrene is not infected and as the name implies, the skin and other affected tissues are dry and black. Sometimes the affected body part will autoamputate or fall off on its own. It is important to monitor dry gangrene closely because it can become infected and turn into wet gangrene. Wet gangrene infections can spread quickly and can be life threatening if not treated. Gas gangrene is another type of infection that occurs deeper under the skin. It usually causes a lot of pain and swelling and needs to be treated surgically as soon as possible.
Arterial ulcers: Ulcers that develop due to a lack of circulation are usually very painful. Blood not only brings oxygen to the body, but also nutrients. The lack of blood flow slows down the healing of these ulcers. For that reason, I often use wound grafts and other advanced wound care products to help speed up the healing of ulcers. Wounds of all types can develop a layer of bacteria that doesn’t cause an infection but keeps the ulcer from healing. It is very important to debride ulcers frequently to remove that layer of bacteria and stimulate the body to heal the ulcer. In ulcers caused by poor circulation, debriding the ulcer can be very painful and sometimes must be done in an operating room where anesthesia can be administered so the patient is comfortable.
Venous stasis ulcers: The second type of ulcer caused by an issue with circulation is a venous stasis ulcer. These ulcers arise from poor circulation of blood from your legs to your heart. Veins are supposed to bring blood back to your heart from your extremities. When veins don’t function correctly, blood pools in your feet, ankles and legs. The pressure from pooling blood causes skin to break down, forming an ulcer. These ulcers can often be prevented by controlling the swelling. This is done by wearing compression stockings or wraps, and elevating your legs above the level of your heart several times a day. Once a venous ulcer has formed, the standard treatment is compression therapy. Compression therapy consists of a tightly wrapped bandage that encourages the fluid in your feet and legs to move back up to your heart.
Diabetic foot ulcers: Diabetic foot ulcers develop in approximately 15 percent of people with diabetes and are the leading cause of non-traumatic lower extremity amputations in the United States. Diabetic foot ulcers are usually caused by lack of feeling in the patient’s feet and poor circulation. Lack of feeling is called neuropathy and can result in injury because normally painful sensations, such as stepping on a pin, cannot be felt and therefore may go unnoticed and untreated.
A small injury can develop into an ulcer because the person doesn’t feel the injury and continues to walk on the injured foot. Diabetes is strongly associated with microvascular disease. Microvascular disease affects the small blood vessels such as the ones in the ends of your fingers and toes. When these vessels are compromised, it can lead to skin break down and ulcer formation. Diabetic ulcers are treated with regular debridements, medicated dressings and reducing pressure on the ulcer.
If an ulcer is not responding to treatment, sometimes a wound graft is used to speed up the healing of the ulcer. There are a number of them available. Some are designed specifically for certain types of ulcers. The decision to use a graft and which one to use should be a decision made by you and your doctor. These are not a first line of treatment but are used on wounds that are not healing after several weeks of treatment with standard wound therapies. Many grafts can be applied in a doctor’s office without the need for anesthesia.
Treating ulcers can be emotionally and physically challenging. The underlying health conditions that lead to the ulcer need to be addressed as well. This may mean you need to see a vascular physician to improve the circulation in your legs or an endocrinologist to help you get your blood sugar under control.
Dr. Katie Evans is a board-certified podiatrist and owner of Range Foot & Ankle in Virginia MN. She provides comprehensive foot and ankle care including surgical options and wound care. Learn more at www.rangefootandankle.com.